In the coding world there is always an emphasis on the importance of documentation. We are all familiar with the saying “If it’s not documented, it wasn’t done”.
We must also place equal importance on making sure all the information that is documented is also translated onto the claim. This is important for a procedure, but also for the diagnosis, which could be the difference between a denied claim and a paid claim.
When it comes to ultrasounds during a pregnancy, there are many procedure codes we need to become familiar with. Along with those procedures there are also very specific diagnosis codes which have to be documented to support the medical necessity. For example, when a patient comes in for their first visit to confirm a pregnancy and a transvaginal is done, some offices report CPT 76817, which is incorrect. The initial transvaginal ultrasound should be reported with CPT 76830 since the pregnancy has not yet been confirmed. Then once it is confirmed and the patient starts to have her routine prenatal visits, then 76817 should be billed.
As the pregnancy continues there are additional conditions that must have the proper diagnoses in order to support medical necessity for those ultrasounds. CPT 76811 – Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation, requires a very specific diagnosis to be considered medically necessary and covered by insurance. Even though some providers perform CPT 76811 as routine quality of care, if the documentation does not support a high risk pregnancy it is not covered. Each insurance has specific regulations pertaining to CPT 76811.
You are encouraged to review the following policies to aid in understanding how third party payers interpret medical necessity:
Take note of Aetna’s policy regarding what conditions meet medical necessity, clinical indicators and criteria required for documentation
United Healthcare has defined clearly the indications for different types of services and clinical evidence based on standards of care from ACOG (American College of Obstetricians and Gynecologists) in their policy on pages 6 and 7
*Follow the policy by each payer for optimal reimbursement
As coders we have to make sure claims are clean to avoid lost revenue. With many EHR systems the diagnosis is automatically transferred onto claims from previous appointments. If they are not corrected before submission to the insurance, they could be denied for not meeting medical necessity.
Although realistically 100% of claims cannot be reviewed before submission, at the very least all ultrasounds and procedures should be reviewed before submission. Having warnings and edits built into certain CPT codes such as 76811 in your practice management software can help with those issues. If there truly is no high risk diagnosis to support medical necessity, then perhaps providers can consider documenting and billing CPT 76805 for routine ultrasound, which is more commonly done at 16-20 weeks of gestation.
Accuracy leads to quality and continuity of care for our patients. This should always be our focus.